This is the Three-Year Johns Hopkins License to use the Guided Care® model and the service mark 'Guided Care' in promotional materials to sell services, to enhance web presence, and for similar purposes. The License also allows application of the very specific Guided Care protocols in your practice, and use of essential forms that will guide the implementation of Guided Care into your practice.

LICENSE COMPONENTS:
This is the Three-Year Johns Hopkins License to use the Guided Care^® model and the service mark "Guided Care" in promotional materials to sell services, to enhance web presence, and for similar purposes. The License also allows application of the very specific Guided Care protocols in your practice, and use of the following essential forms that will guide the implementation of Guided Care into your practice:
- Guided Care Health History Questionnaire
- Guided Care Preliminary Care Guide
- Guided Care Care Guide
- Guided Care Action Plan

This Solution page is for the Guided Care license only. For hospitals, health systems or practices who would like to fully implement the Guided Care Model, please contact us here: Solutions@MX.com.

Below you will find a series of questions and answers that will guide you through the objectives, implementation, performance and outcomes of the Guided Care Model.

Guided Care® is a new solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. A Guided Care nurse, based in a primary care office, works with 2 to 5 physicians and other members of the care team to provide coordinated, patient-centered, cost-effective health care to 50 to 60 of the practices' chronically ill patients. The Guided Care nurse conducts in-home assessments, facilitates care planning, promotes patient self-management, monitors conditions monthly, coordinates the efforts of all health care professionals, smoothes transitions between sites of care, educates and supports family caregivers, and facilitates access to community resources. This program will help integrate the many aspects of care for this growing segment of the population, resulting in better care for patients and efficiencies for outpatient centers.

What problems does the Solution address?
Guided Care addresses the problem of a lack of an efficient, cost-effective way to respond to the needs of patients with either chronic illnesses or co-morbidities. Research shows that Guided Care reduces the use of expensive health services for chronically ill older adults.

How was the Solution developed?
The Guided Care model is shaped by the lessons of 30 years of research in chronic care. In research conducted at the Johns Hopkins Bloomberg School of Public Health (the leading school of public health as ranked by the annual U.S. News and World Report survey), Guided Care is designed to translate the best available scientific evidence and the most effective health care processes into routine use in primary care practices. Preliminary results from the research trial indicate that Guided Care improves the quality of patients' care, improves family caregivers' perception of quality, improves physicians' satisfaction with chronic care, improves nurses' job satisfaction, and may reduce the use of expensive services.

Unlike most care/case management interventions, Guided Care focuses on the role of the Guided Care Nurse, who:
- is based in the primary care physician's office.
- works with the patient long-term, usually for life.
- provides intensive transitional care.
- uses motivational interviewing to help patients manage their conditions.
- provides continuing education, resources, and support for family caregivers.

What does it take to implement? Maintain?
Guided Care is a well-defined model of care that primary care practices and outpatients clinics can fully implement in 6-9 months. Implementation involves (1) having a registered nurse(s) within the practice who has completed the course in Guided Care Nursing and (2) integrating the nurse into the practice. Organizations are required to obtain a license from Johns Hopkins University in order to use the Guided Care model and use the service mark "Guided Care" in promotional materials . The license also states eight (8) services that must be followed in the care of a practice's chronically ill older patients:
- Assess the patient at home.
- Create an evidence-based comprehensive "Care Guide" (a tool for providers that summarizes the patient's conditions, medications, care providers, family members and other important data in a succinct and professional format) and "Action Plan" (a patient-friendly version of the Care Guide).
- Promote patient self-management.
- Monitor the patient's conditions monthly.
- Monthly proactive monitoring
- Coordinate the efforts of all the patient's health care providers.
- Smooth the patient's transitions between sites and providers of care.
- Assess, educate, and support family caregivers.
- Facilitate access to community resources.

How did you measure Solution success? Based on a 32-month research trial from 2006-2009:
- Improves the quality of patients' care
- Improves family caregivers' perception of quality
- Improves physicians' satisfaction with chronic care
- Produces high job satisfaction among Guided Care Nurses
- May reduce the use of expensive services, especially in integrated healthcare delivery systems